A 2-year-old presents with anal fissures but no history of constipation. The clinician should be most concerned about which possibility?

A 2-year-old presents with anal fissures but no history of constipation. The clinician should be most concerned about which possibility?

• A. Ulcerative colitis
• B. Crohn’s disease
• C. A foreign body
• D. Sexual abuse

Answer: (D)

Anal fissures in a toddler are most often related to hard stools and constipation, but when there is no history of constipation, this finding becomes a red flag for potential anal trauma from sexual abuse. In children as young as 2 years old, fissures can indicate forced penetration or other abusive contact, which mandates immediate safeguarding actions. The clinician should respond to this concern by ensuring the child’s safety, conducting a careful, nonleading assessment, documenting the lesion objectively, and involving child protective services or the appropriate child protection system per local requirements. This approach also includes looking for other signs of abuse and coordinating with a multidisciplinary team to support the child. While inflammatory bowel disease or a foreign body can cause anorectal symptoms, they do not fit as well here without other supporting signs (such as chronic GI symptoms for IBD or acute, localized signs of foreign body with obstruction or retention).

Anal fissures in a toddler are most often related to hard stools and constipation, but when there is no history of constipation, this finding becomes a red flag for potential anal trauma from sexual abuse. In children as young as 2 years old, fissures can indicate forced penetration or other abusive contact, which mandates immediate safeguarding actions. The clinician should respond to this concern by ensuring the child’s safety, conducting a careful, nonleading assessment, documenting the lesion objectively, and involving child protective services or the appropriate child protection system per local requirements. This approach also includes looking for other signs of abuse and coordinating with a multidisciplinary team to support the child.

While inflammatory bowel disease or a foreign body can cause anorectal symptoms, they do not fit as well here without other supporting signs (such as chronic GI symptoms for IBD or acute, localized signs of foreign body with obstruction or retention).